PROOF OF INSURANCE (2022 - 2023) CLOSED11 ll CERTIFICATE OF LIABILITY INSURANCE D 0111 no22
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
Danmar Insurance Services Inc.
License # OD36873
9899 Indiana Avenue, Ste 101
Riverside CA 92503
NONE T Blanca De La Hoz
NE (51) 509 0509 Na r (961 t"WO615
A D CSbleacad@danma,iins.com
INSURE S AFFORDING 00tVOR01,0 ~
NAIC 9
INSURERA: Travelers Property Casualty Cc of America
25674
INSURED
Dann Engineers, Inc.
3914 Del Amo BL, Ste 921
Torrance CA 90503
INSURER B: Pacific Compensation Insurance Company
11555
INSURERC: QBE North America Insurance Group
INSURER D :
INSURER E :.
INSURERF:
nnvFRAnPA CERTIFICATE NIIMAF:Rr CL2211110456 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
POLICY NUMBER
POUCYEFF
POLLCY EXP
LIMITS
* ' COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 11000,000
CLAIMS -MADE a OCCUR
FREMI aES f5a o
$ 1,000,000
MED EXP one rson
s 5,000
A
Y
680-9N963609-21-47
09101/2021
09/01/2022
PERSONAL SADVINJURY
$ 1,000.000
GEN'LAGGREGATELIMIT APPLIES PER:
P1POLICY JET Loc
GENERALAGGREGATE
$ 2,000,000
PRODUCTS -COMPIOPAGG
$ 2,000,000
Employee dishonesty
s 75,000
OTHER.
AUTOMOBILE LIABILITY
E aoc9dan100 LIMIT
i
AWAUTO
BODILY INJURY (Per person)
$
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY AUTOS ONLY
BODILY INJURY (Par accident)
i
P
araotl' '
$
i
UMBRELLA LIAB
OCCUR
EACH OCCURRENCE
$
Id
EXCESS LIAR
CLAIMS -MADE
AGGREGATE
$
DED I I RETENTION $
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIErORIPARTNERIEXECUTIVE YIN
OFFICER/MEMBER EXCLUDED?
(Mandatory In BE �
NIA
Y
WA-007255-01
02/01/2022
02/01/2023
.
0-4 STATUTE ER
EL.EACHACCIDENT
$ 1,000,000
E.L.DISEASE-ID EMPLOYEE1000,000
i
EL. DISEASE -POLICY LIMIT
i 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
Each Claim Limit
$1,000,000
C
Professional Liability
JLANE43701-02
11/07/2021
11/07/2022
Aggregate Limit
$1,000.000
11
DESCRIPTION OF OPERATIONS r LOCATIONS I VEHICLES (ACORD 101, Additional Remaft Schedule, may be attached If more apace la required)
Re: As per Contract or Agreement on file with the insured.
City of Ell Segundo Public Works Department, Its officers elected and appointed officials employees and volunteers are included as additional insured on the
General Liability policy CGD381 0915 endorsement attached.Workers Compensation Waiver of Subrogation endorsement WC990316.
`WORKERS COMPENSATION POLICY RENEWED'
City of El Segundo, Public Works DepartmentAttn: Floriza Rivera
350 Mein Street
ElSegundo
CA 90245
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WRH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016103)
The ACORD name and logo are registered marks of ACORD
CERTIFICATE OF LIABILITY INSURANCE DATE(M1)4/0812022YYY)
/2�22
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY
AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),
AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the ollc les must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION Is WAIVED, subject to the terms and
conditions ofthe policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu ofsuch endorsements)
........ ...... _ _. ...............
PRODUCER CONTACT
NAME:
Michael Delaney(2958C5T) PHONE �... FAX IT..........
A 787 0039
2340 Plaza Del Amo Ste 200 (/c, No, EXT): 310 782 8586 (A/c, No : 3 0- � M....�
E-MAIL
Torrance CA 90501-3453 ADDRESS: mdelaney@farmersagent.com
INSURER(S) AFFORDING COVERAGE NAIC4
. INSURED .. --------------- _._. INSURER A: TTUCI< Insurance Exchange_ 21709
INSURERB: Farmers Insurance Exchange _ 2166
2
DENN ENGINEER INC INSURERC: Mid Century Insurance "Company 21687
3914 DEL AMO BLVD STE 921 mm'ITIT �IT�
INSURER D:
.......................
TORRANCE CA 90503 INSURER E:
INSURER F:
COVERAGES
CERTIFICATE NUMBER: REVISION NUMBER:
_....._ ........ .................... __----------.... ..
THIS ISTO CERTIFYTHATTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUEDTOTHE INSURED NAME ABOVE FORTHE POLICY PERIOD INDICATED, NOTWITHSTANDING ANY
REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE
POLICIES DESCRIBED HEREIN IS SUBJECTTO ALLTHETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
mmTYPEOFINSURANCE
INSR
LTR
ADDTL SUER POLICY EFF POLICYEXP
POLICY NUMBER LIMITS
INSD WVD (MM/DD/YYYY) (MM/DD/YYYY)
_...' _._.
COMMERCIALGENERALLIABILITY
_..m ...._-----------
EACH OCCURRENCE $
..
..._ .. _
DAMAGE
$
CLAIMS -MADE OCCUR
�J
(Eaocc occurrence)
PREMISES (Ea Occurrence
...
MED EXP (Anyone person) $
.... ....................
PERSONAL &ADV INJURY $
-----------------.,,,,.. ................
GEN'L AGGREGATE LIMITAPPLIES PER
GENERAL AGGREGATE $
POLICY PROJECT LOC
PRODUCTS-COMP/OPAGG $
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $ 2,000,000
(Ea accident)
.......................... ...............
ANYAUTO
BODILY INJURY (Per person) $
OWNEDAUTOS SCHEDULED
C X
BODILY INJURY (Per accident) $
ONLY AUTOS
Y Y 606665017 09/13/2021 09/13/2022
xHIREDAUTOS X NON -OWNED
PROPERTY DAMAGE $
ONLY AUTOSONLY
(Per accident)
$
_ --
UMBRELLA LIAB OCCUR
_ ._ ..... .
EACH OCCURRENCE $
CLAIMS-MADE
EXCESS LIAB�EIENTION
AGGREGATE $
................ .........-....
DED $
WORKERS ION
PER OTHER $
AND EMPLOYERS' LIABILITY
STATUTE
ANY PROPRIETOR/PARTNER/ Y/N
E.L. EACH ACCIDENT $
EXECUTIVE OFFICER/MEMBER
N/A
E.L. DISEASE - EA EMPLOYEE
EXCLUDED? (Mandatory In NH)
...
Ifyes, describe under DESCRIPTION OF
E.L. DISEASE -POLICY LIMIT $
OPERATIONS below
...----------_.
DESCRIPTION 0�. _._.
F OPERATIONS/LOCATIONS/VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space is required)
Topographical Survey
Douglas St & Coral St
El Segundo, CA 90245
CERTIFICATE HOLDER
.............. ... .......... ._... �._...._.,_
CANCELLATION
—CItyO EI-Segun O Ubllc
.........................
or S Departmeni SHOULD ANY OFTHE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
350 Main St,
DATE THEREOF, NOTICE WILL BE DELIVER D IN ACCORDANCE WITH THE POLICY PRO
mmmmmmmmisloNs,
El Segundo, CA 90245
AUTWdt1 ARE stNiATIVE
� � n
ACORD 25 (2016/03) @1988-2015 ACORD CORPORATION. All Rights Reserved
81-17rq 11-15 The ACORD name and logo are registered marks of ACORD
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED
(ARCHITECTS, CTS, ENGINEERS S AND SURVEYORS)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
1. The following is added to SECTION II — WHO IS
AN INSURED:
Any person or organization that you agree in a
"written contract requiring insurance" to include as
an additional insured on this Coverage Part, but:
a. Only with respect to liability for "bodily injury',
"property damage" or"personal injury"; and
b. If, and only to the extent that, the injury or
damage is caused by acts or omissions of
you or your subcontractor in the performance
of "your work" to which the "written contract
requiring insurance" applies, or in connection
with premises owned by or rented to you.
The person or organization does not qualify as an
additional insured:
c. With respect to the independent acts or
omissions of such person or organization; or
d. For "bodily injury", "property damage" or
"personal injury" for which such person or
organization has assumed liability in a
contract or agreement.
The insurance provided to such additional insured
is limited as follows:
e. This insurance does not apply on any basis to
any person or organization for which
coverage as an additional insured specifically
is added by another endorsement to this
Coverage Part.
f. This insurance does not apply to the
rendering of or failure to render any
"professional services".
g. In the event that the Limits of Insurance of the
Coverage Part shown in the Declarations
exceed the limits of liability required by the
"written contract requiring insurance", the
insurance provided to the additional insured
shall be limited to the limits of liability required
by that "written contract requiring insurance".
This endorsement does not increase the
limits of insurance described in Section III —
Limits Of Insurance.
h. This insurance does not apply to "bodily
injury" or "property damage" caused by "your
work" and included in the "products -
completed operations hazard" unless the
"written contract requiring insurance"
specifically requires you to provide such
coverage for that additional insured, and then
the insurance provided to the additional
insured applies only to such "bodily injury" or
"property damage" that occurs before the end
of the period of time for which the "written
contract requiring insurance" requires you to
provide such coverage or the end of the
policy period, whichever is earlier.
2. The following is added to Paragraph 4.a. of
SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
The insurance provided to the additional insured
is excess over any valid and collectible other
insurance, whether primary, excess, contingent or
on any other basis, that is available to the
additional insured for a loss we cover. However, if
you specifically agree in the "written contract
requiring insurance" that this insurance provided
to the additional insured under this Coverage Part
must apply on a primary basis or a primary and
non-contributory basis, this insurance is primary
to other insurance available to the additional
insured which covers that person or organizations
as a named insured for such loss, and we will not
share with the other insurance, provided that:
(1) The "bodily injury" or "property damage" for
which coverage is sought occurs; and
(2) The "personal injury" for which coverage is
sought arises out of an offense committed;
after you have signed that "written contract
requiring insurance". But this insurance provided
to the additional insured still is excess over valid
and collectible other insurance, whether primary,
excess, contingent or on any other basis, that is
available to the additional insured when that
person or organization is an additional insured
under any other insurance.
CG D3 81 0915 ® 2015 The Travelers Indemnity Company. All rights reserved. Page 1 of 2
Includes the copyrighted material of Insurance Services Office, Inc., with Its permission
COMMERCIAL GENERAL LIABILITY
3. The following is added to Paragraph 8., Transfer
Of Rights Of Recovery Against Others To Us,
of SECTION IV — COMMERCIAL GENERAL
LIABILITY CONDITIONS:
We waive any right of recovery we may have
against any person or organization because of
payments we make for "bodily injury", "property
damage" or "personal injury" arising out of "your
work" performed by you, or on your behalf, done
under a "written contract requiring insurance" with
that person or organization. We waive this right
only where you have agreed to do so as part of
the "written contract requiring insurance" with
such person or organization signed by you
before, and in effect when, the "bodily injury' or
"property damage" occurs, or the "personal Injury'
offense is committed.
4. The following definition is added to the
DEFINITIONS Section:
"Written contract requiring insurance" means that
part of any written contract under which you are
required to include a person or organization as an
additional insured on this Coverage Part,
provided that the "bodily injury" and "property
damage" occurs and the "personal injury" is
caused by an offense committed:
a. After you have signed that written contract;
b. While that part of the written contract is in
effect; and
c. Before the end of the policy period.
Page 2 of 2 ® 2015 The Travelers Indemnity Company. All rights reserved. CG D3 8109 15
Includes the copyrighted material of Insurance Services Office, Inc., with its permission
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
'" " WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT -
'�,� CALIFORNIA
A CopperPolnt Insurance Company
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce
our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you
perform work under a written contract that requires you to obtain this agreement from us).
You must maintain payroll records accurately segregating the remuneration of your employees while engaged in the
work described in the Schedule.
The additional premium for this endorsement shall be 5.00 % of the California workers' compensation premium
otherwise due on such remuneration (minimum $ loo . oo ).
Schedule
Person or Organization Job Description
City of El Segundo Engineering work
Public Works Department
350 Main Street
E1 Segundo, CA 90245
This endorsement changes the policy to which it is attached and is effective on the policy effective date unless otherwise stated.
This endorsement, effective on 02-01-22 at 12:01 A.M. standard time, forms a part of
Policy Number WA-007255-01 of the Pacific Compensation Insurance Company
Policy Effective Date 02-01-22 to 02 -01-23 NCCI Carrier Code 11555
Insured Name Denn Engineers Endorsement No. 1
ISSUED 01/10/22 AT 09:29 AM BY U59
Premium $
Countersigned at ,,sand Oaks. CA -on y
2000-12-0119W Authorized -Representative
WC 99 03 16 (Ed+-14)